Thank you for agreeing to contribute to an issue of Continuum. This brief guide outlines your responsibilities when writing for Continuum.

Transcription

1 Thank you for agreeing to contribute to an issue of Continuum. This brief guide outlines your responsibilities when writing for Continuum. HONORARIA You will receive an honorarium and a one-year complimentary subscription to Continuum as author of the patient management problem (PMP). All honoraria are paid upon publication of the issue. PATIENT MANAGEMENT PROBLEM INSTRUCTIONS Each issue of Continuum is accompanied by one PMP and is eligible for CME along with the multiple-choice questions in each issue. The following instructions should assist you in crafting this important CME component of Continuum. Case Selection Each PMP CME component of Continuum is based on an extended case covering a topic detailed elsewhere in the Continuum issue. You may use an actual clinical case with patient identifiers omitted or changed. The case should be rich and full of information, creating a lifelike picture when the case is presented. As you develop the case, identify different teaching points as they arise. These teaching points will be framed as multiplechoice questions. Strive to use clinically important, but not esoteric, cases. Of course unusual cases may provide useful information about common disorders, as well. Learning Objective(s) One or more brief learning objectives should be stated at the beginning of the PMP. Format A PMP should be presented in the form of a narrative of progressive disclosures. As the case unfolds, ambiguities help avoid early closure. Predictions or assumptions are included at various points as they would be when establishing a differential diagnosis. Each case should focus on the following, as applicable: case history, examination, diagnostic evaluation, management, and therapy. At crucial points within each part of the case narrative, include key questions regarding decisions that need to be made in order to proceed. Each question should be accompanied by a set of five answer options. However, only one best answer should apply. There must be 12 questions total for the entire activity. Having only one or two questions between each narrative aspect of the case may work best. The multiple-choice question should allow the reader to decide, for example, what to specifically ask in the history, what examination finding is most likely to be 1

2 seen, what is the most appropriate next step in diagnosis, what is the most appropriate next step in treatment, etc. The reader could also be asked to interpret the given MRI finding or other diagnostic test result, rather than you, as author, interpreting this in the case. As the case unfolds, the answer for the preceding question will usually be apparent; this is expected. You may use tables and figures when necessary, but keep in mind that they must relate to the case at hand. It is best to use these when presenting information about the patient or his or her test results that would be better presented in tabular format (eg, a list of the patient s medications and their doses, a list of blood test results, etc). Similarly, figures can be used to demonstrate a patient s test result (eg, MRI, CT, EEG) or as a starting point for a question. Please note that you should not include general informational tables and figures regarding the topic (list of relevant clinical trials, table of the best tests for diagnosing a particular disorder, figure demonstrating the pathophysiology of a disease). Question-Writing Tips Each question must include five answer options. Do not ask which of the following is true/false. Do not ask all of the following except. Avoid factoid questions that test basic medical knowledge unrelated to the decision point being addressed in the case Do not use all of the above or none of the above as an answer option. Preferred Responses Following each question and its answer options, please indicate the preferred response and include a brief discussion explaining why the correct answer is correct and also why the other options are not. When more than one option is reasonable, specifically discuss why you (as the expert) chose one option over other potentially appropriate options. These explanations will appear in a preferred responses section separate from the case in the print issue despite the fact that the "correct response" may often be inferred by the way the case subsequently unfolds after the multiple-choice question. References Continuum is approved as a lifelong learning (CME) activity for Maintenance of Certification by the ABPN. As such, recommended literature resources must be included with the discussion for each question and cited numerically. This recommended literature may come directly from a chapter in the Continuum issue itself, but references to outside articles are highly encouraged. A modified Vancouver style of listing references is used. Don t worry about submitting references in this style; all references will be changed to conform to the Continuum style during the editing process. Be sure, however, to include one or more full references for each discussion section. Informed Consent Continuum adheres to the International Committee of Medical Journal Editors (ICMJE) 2

3 standards regarding informed consent as specified in II.E.1. of its Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication ( Identifying information, including patients names, initials, hospital numbers, or facial features, should not be included in case reports or figures. If this information is essential for scientific purposes, you must submit written informed consent from the patient to the editorial office. Manuscript Submission All components of your article should be submitted to Continuum s Editorial Manager manuscript submission site at You will receive an with your user name and password, but you can also contact the editorial office for this information. Please send any questions you have about writing for Continuum to Andrea Weiss, Executive Editor, at aweiss@aan.com or , or Amanda Tourville, Program Manager, at atourville@aan.com or Following is an excerpt from a recent PMP that may help you to better understand the activity. Please contact either Andrea or Amanda if you would like more examples of recently published PMPs. Thank you for writing for Continuum. EXCERPT FROM RECENT PMP The following Patient Management Problem was chosen to reinforce the subject matter presented in the issue. It emphasizes decisions facing the practicing physician. As you read through the case you will be asked to complete 12 questions regarding history, examination, diagnostic evaluation, therapy, and management. For each item, select the single best response. Learning Objectives: Upon completion of this activity, the participant will be able to: Localize and provide a differential diagnosis of weakness and fever in a patient with this clinical presentation Recognize the role of neuroimaging studies, neurophysiologic tests, and other laboratory studies in diagnosis of a patient with this clinical syndrome Discuss the management of a patient with weakness and possible impending respiratory failure Case A 55-year-old man with a history of hepatitis C, cirrhosis, and type 1 diabetes mellitus presents in August to the medicine service after 2 days of malaise, weakness, fever, body aches, and bilateral upper extremity weakness. On the day of admission, he is unable to lift his right arm off of the bed and can only bend his left arm at the elbow. The patient also reports poor appetite, nausea, and mild dry cough but no vomiting or diarrhea. On examination, the weakness appears to be diffuse, involving the deltoids, biceps, triceps, and wrist extensors more severely, with more mild distal weakness. 1. Which of the following features on examination would be most helpful in distinguishing between an upper motor neuron and lower motor neuron localization 3

4 for the patient s weakness? A. decreased sensation to pinprick in the arms B. decreased tone in the arms C. hyperreflexia in the legs D. hyporeflexia in the arms E. right facial weakness The preferred response is C. Although hyporeflexia and decreased tone in a weak limb usually signify a lower motor neuron localization, acute upper motor neuron lesions often present similarly for a few days before the more classic hyperreflexia and increased tone occurs. 1 Therefore, in this acute setting, these features may not be helpful. Facial weakness can occur with both upper and lower motor neuron causes of weakness, although the pattern of weakness (eg, sparing of the forehead with upper motor neuron etiologies) may be helpful. Increased reflexes in the lower extremities would likely indicate involvement of upper motor neurons. If reflexes were decreased in the upper extremities and increased in the lower extremities, a cervical spine localization would be most likely. 1. Brazis PW, Masdeu JC, Biller J. Localization in clinical neurology. 6th ed. Philadelphia: Lippincott Williams & Wilkins, Which of the following bedside tests would be most helpful in assessing this patient s respiratory function? A. chest auscultation B. facial strength C. forced vital capacity D. pulse oximetry E. respiratory rate The preferred response is C. The best method for neuromuscular respiratory evaluation is pulmonary function testing via a forced vital capacity and a mean inspiratory force. 1 An alternative option is to assess cough peak flow. Cough peak flow minimizes the effort-dependent variation in peak flow rate and is typically reduced in patients with neuromuscular weakness, making it a more reliable assessment of expiratory muscle strength. Respiratory rate, chest auscultation, and pulse oximetry will most likely be normal and not indicative of neuromuscular respiratory compromise. Facial strength, while helpful, is not clearly correlated with respiratory function. 1. Sharma GD. Pulmonary function testing in neuromuscular disorders. Pediatrics 2009;123(suppl 4): S219-S221. 4

5 During the first day of hospitalization, the patient develops a temperature of 38.5 C (101.3 F) without serum leukocytosis and is started on vancomycin and gentamicin. His arm weakness progresses to the point of near-complete paralysis. 3. Which of the following serum studies should be included in the evaluation of this patient s bilateral arm weakness given his underlying conditions? A. ammonia B. cryoglobulins and hepatitis C viral load C. hemoglobin A1C D. lactate dehydrogenase E. serum protein electrophoresis The preferred response is B. Given his history of hepatitis C, hepatitis C viral levels and serum cryoglobulins should be included in the serum evaluation given their association with both polyneuropathy and, on rare occasions (case reports), an upper cervical myelopathy (noted in cases of hepatitis C viral infection without cyroglobulinemia). 1 An elevated ammonia may shed light on his encephalopathy but would not be helpful for evaluating his pattern of weakness. 1. Mestre TA, Correia de Sa J, Pimentel J. Multifocal central and peripheral demyelination associated with hepatitis C virus infection. J Neurol 2007;254(12): Given the patient s history of abrupt worsening associated with fever and antibiotic administration, which of the following neurologic conditions should be especially considered in the differential diagnosis? A. chronic inflammatory demyelinating polyneuropathy B. multifocal motor neuropathy C. multiple sclerosis D.myasthenia gravis E. polymyositis The preferred response is D. Although all of the answer options are conditions that can lead to bilateral arm weakness, abrupt worsening in the setting of administration of an aminoglycoside should trigger consideration of a neuromuscular junction disorder such as myasthenia gravis. 1 A variety of systemic infections and stresses can trigger myasthenic crisis, but in the hospital setting it is important to be aware of the variety of medications that can exacerbate myasthenia, including antibiotics (aminoglycosides, tetracyclines, fluoroquinolones, erythromycin, and others). 5

6 1. Meriggioli MN. Myasthenia gravis: immunopathogenesis, diagnosis, and management. Continuum Lifelong Learning Neurol 2009;15(1): The patient quickly develops encephalopathy. On mental status evaluation, he is able to state his name but is otherwise disoriented. He is able to recall only four digits forward and two digits backward. He is able to count to only 12 in one breath. 5. Given the recent change in his condition, which of the following actions would be most important in this patient at this time? A. change his antibiotics for a broader spectrum of microbial coverage B. obtain an arterial blood gas C. obtain bedside pulmonary function tests and transfer to the intensive care unit D. obtain an ECG and check cardiac enzymes E. send off new serum studies including complete blood count, chemistry panel, and liver function tests The preferred response is C. Bedside pulmonary function testing should be one of the first courses of action given his degree of progressive neuromuscular weakness and developing encephalopathy. 1 The bedside test of counting numbers in a single breath is a reasonable surrogate for neuromuscular respiratory weakness; certainly less than 20 digits (in this case 12) is concerning. Furthermore, he is becoming encephalopathic, raising concern for a parenchymal infectious process. His antibiotic coverage should be broadened concomitantly to cover a possible bacterial meningoencephalitic condition. An arterial blood gas is reasonable during the workup, although it is less likely to yield abnormalities until the neuromuscular respiratory compromise becomes more severe. The pulmonary function tests will likely be more useful in making a decision regarding ventilatory support at this point. 1. Rabinstein AA, Wijdicks EF. Warning signs of imminent respiratory failure in neurological patients. Semin Neurol 2003;23(1):